Every finding on record at Lyra Hospice

Observed in Record Review. In 3 of 5 patient records reviewed, During HV#1 record review it was noted the goals were measurable and most would be achieved within 14 days or 2 weeks. For example: pt will maintain optimal mobility during care within 14 days, pt's pain will remain at a comfortable level during care within 48hours period of time, fall prevention will be maintained, pt will achieve optimal sleep/rest during care within 2 weeks, patient/caregiver will achieve optimal grief reaction prior to patient's death. During HV#2 record review it was noted the goals were not measurable: caregiver/family will understand signs and symptoms of dying process prior to pt's death, pt/caregiver will achieve optimal grief reaction prior to patient's death, pt will maintain optimal mobility during care within 2 weeks period of time, patient's pain will remain at a comfortable level during care within a 2 week period of time, skin integrity will be maintained, pt/caregiver will verbalize understanding of medications and treatments during care, skin will be maintained at an optimal level during care. During HV#3 record review it was noted the goals were not measurable, with end dates of 2 weeks for most goals: pt. will maintain optimal mobility during care within 2 weeks, patient pain will remain at a comfortable during care within 2 weeks, patient will receive optimal sleep/rest during care within 2 weeks. This was discussed with the DPCS designee.

Observed in Record Review. In 3 of 3 patient records reviewed, During HV#1, #2 and #3 record review it was noted the POCs were not individualized and did not reflect the clinical findings from the RN initial assessments. The POCs included interventions related to imminent death but, the patients were not actively dying. For example: the following intervention on the POCs to instruct on terminal care/impending death lacked documentation by the RN on the initial assessments of clinical findings that indicated the patients were imminently terminal with impending death. This was discussed with the DPCS designee.